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RICHMOND — Virginia hospitals are monitoring painkiller prescriptions more closely and taking other steps to curb the opioid epidemic, and the efforts may be paying off: Drug overdoses in Virginia have dropped for the first time in six years.

In 2016, the opioid epidemic was declared a public health emergency in Virginia. Fatal opioid overdoses increased steadily from 572 in 2012 to 1,230 in 2017. Last year, however, the number of deaths dipped, to 1,213, according to preliminary statistics released this week by the Virginia Department of Health.

The decrease coincided with data from the U.S. Centers for Disease Control and Prevention showing a decline in overall prescriptions of opioids — and with moves by Virginia officials and physicians to apply more scrutiny before issuing such prescriptions.

Dr. Charles Frazier, senior vice president at Riverside Health System in Newport News, said his medical practice and others across Virginia are prescribing narcotics in a more controlled and efficient way.

Frazier was involved in the creation of Virginia’s Emergency Department Care Coordination program.

Established by the General Assembly in 2017, the EDCC’s purpose is to “provide a single, statewide technology solution that connects all hospital emergency departments in the Commonwealth” for the purpose of extending and improving patient care, according to ConnectVirginia, a statewide health information exchange.

“The purpose of the EDCC is to integrate alerts,” Frazier said. “It shows us alerts of whether or not they (patients) have been in other emergency departments, information on how they were treated, with the idea being if a patient came in: Who is their primary care doctor? Who can we connect them to?”

Frazier said that in the program’s first phase, all hospitals in Virginia were required to submit a year or two of historical patient visit data to the EDCC information exchange by June 2017.

“The system is set up to alert emergency department providers and staff if the patient is a frequent emergency department patient, and also if they have been aggressive or abusive to staff,” Frazier said.

Frazier said that most of the time, the system is used to direct patients to proper care.

“I think part of the problem is if people have a hard time with transportation, they go to the ER for basic health care,” Frazier said. “If you go to the emergency room for a sore throat, for example, that can be expensive.”

The second phase of the EDCC, which was implemented last July, involves notifying primary care doctors if their patient is in the emergency department. If the system can identify a patient’s primary care doctor, it will send an alert.

“One thing we are starting to see are health systems collaborate on patients,” Frazier said. “There was a patient at Bon Secours who kept going to various emergency departments around Richmond — VCU, St. Francis, and others. With the EDCC program, they could see where they had been to, and the health systems worked together, along with the insurance company, to help the patient get the primary care they needed.”

Virginia’s Prescription Monitoring Program

Gov. Ralph Northam, a physician himself, helped create the EDCC. He also has been an advocate for the state’s Prescription Monitoring Program.

Under that program, Frazier explained, “Every time a pharmacy prescribes a controlled substance, they need to submit the information to the state — the duration, the dosage — and the system tracks how many times and how many providers have prescribed to the patient.”

Virginia Board of Medicine regulations require seeing chronic pain patients every 90 days and conducting drug screens to make sure patients are taking their medications and not taking illicit substances. Regulations also require prescribing an opioid antidote in certain high-risk situations.

Health officials’ concerns about opioids have grown as fatal overdoses spiked over the past decade. Preliminary numbers show that 1,484 people died from drug overdoses in Virginia in 2018. That is more deaths than from guns (1,036) and traffic accidents (958).

The total number of overdose fatalities was down slightly from 1,536 in 2017.

The number of prescription opioid deaths dropped from 507 in 2017 to 457 last year. On the other hand, deaths from heroin and/or fentanyl jumped from 940 to 977.

‘These numbers should give us some optimism’

In a press release, Attorney General Mark Herring thanked “advocates, families, doctors, recovery communities, elected officials, public health professionals and others who have helped reduce Virginia’s number of fatal drug overdoses for the first time in six years.”

Herring has been a strong advocate for fighting the opioid epidemic. He has taken a range of actions — from pushing to expand the Prescription Monitoring Program, to producing a documentary titled “Heroin: The Hardest Hit,” to suing Purdue Pharma, the creator of Oxycontin, on grounds that it helped create and prolong the opioid epidemic in Virginia.

“We should be heartened and hopeful to see that overdose deaths seem to have plateaued and may be starting to decline, but nearly 1,500 overdose deaths, mostly from opioids, is still a staggering number that shows this epidemic is far from over,” Herring said.

“But these numbers should give us some optimism that Virginia’s comprehensive approach — emphasizing treatment, education, and prevention, along with smart enforcement — can produce results and save lives.”

New controls on opioid prescriptions

Frazier said the biggest impact on the opioid epidemic might stem from rules imposed last year by the Virginia Board of Medicine.

“Across the state,” Frazier said, “we’ve seen a decrease in the number of opioid prescriptions and the duration of treatment for acute pain — a tremendous difference.”

Frazier said opioids sometimes are appropriate and sometimes aren’t.

“There are people who break their leg and need it for a few days, but for people who have chronic pain, they may require ongoing opioids for a long time,” he said. “While we first try non-opioid therapies, the reality is sometimes opioids are the most effective treatment for chronic pain.”

Patients can self-administer pain relief

When opioids are appropriate for treatment, health care professionals want to ensure that patients can receive their medication safely and easily. Virginia Commonwealth University Medical Center Hospitals have a specific technique allowing patients to self-administer drugs.

Samantha Morris, a care partner at the center’s Emergency Department, said narcotics can be administered directly to a patient, by the patient, with the press of a button. This involves a device called a patient-controlled analgesia pump.

“Fentanyl is usually what I see being prescribed the most, and that one is usually administered through a PCA pump,” Morris said. “It delivers some form of narcotic, usually fentanyl, and the patient presses a button to administer themselves a dose every five to ten minutes, depending on the drug.”

The amount of time a dosage from the PCA pump can be administered is based on the strength of the drug prescribed.

“I see patients mostly in the burn victim unit because they’re in a lot of pain,” Morris said.

Morris said she sees patients come in for opioid-related incidents all the time.

“It’s really difficult, because if a patient is addicted to any kind of substances, whether it’s amphetamines or any kind of narcotic to begin with, we can’t administer pain management, because it’s not going to affect the same pathway.”

Tucked between news of budget meetings and beauty pageant winners published in The Dickenson Star’s 2017 “Year in Review” is a grim statistic: Dickenson County was first in the state and sixth in the nation in opioid overdose deaths per capita.

In Dickenson County, in the coalfields of Southwest Virginia bordering Kentucky, residents have been dying of prescription opioid overdoses in recent years at a rate of about 40 per 100,000 people – more than seven times the statewide rate.

The newspaper’s annual review is cited in the introduction of a lawsuit filed by Dickenson County against 30 pharmaceutical manufacturers, distributors and providers including Purdue Pharma, Abbott Laboratories and CVS Health Co.

Represented by the Sanford Heisler Sharp law firm and the Cicala Law Firm, Dickenson is suing for $30 million in damages. The suit says the defendants deliberately increased the flow of opioids into the county, state and country.

The case is one of the latest examples of communities across the nation suing pharmaceutical companies and associated businesses and alleging that they had a role in creating the epidemic. In Virginia, the city of Alexandria is suing for $100 million while in neighboring Maryland, Montgomery and Prince George counties have also taken legal action.

Joanne Cicala, founder of the Cicala Law Firm, which has offices in Texas and New York, says those who are responsible for and profited from the epidemic must be held accountable for its costs.

“The opioid epidemic is not accidental. It is not a natural disaster; it is a man-made crisis,” Cicala said. “And worse – the companies that did this were not just seeking to build market share – they knew they were creating addicts.”

In more than 100 pages, the lawsuit tells the story of how Dickenson County – with a population of fewer than 16,000 residents spread out over 334 square miles – was drawn into a prescription opioid overdose epidemic that claimed more than 500 lives across the state in 2017.

Did manufacturers ‘push opioid as safe, effective drugs’?

As with any drug that enters the prescription market, the distribution process begins with manufacturers. In the case of the opioid epidemic, one of the manufacturers is Purdue Pharma, a company known for its best-selling opioid – OxyContin.

In Dickenson County, the lawsuit claims, Purdue Pharma and other defendants recognized “the enormous financial possibilities associated with expanding the opioid market.” So they “rolled out a massive and concerted campaign to misrepresent the addictive qualities of their product, and to push opioids as safe, effective drugs for the treatment of chronic pain,” the suit alleges.

According to the lawsuit, the drug manufacturers took part in a “campaign of deception” rooted in a since-disavowed study by Dr. Russell Portenoy published in the medical journal Pain in 1986.

In the study, Portenoy claimed that opioids could be used for long periods of time “without any risk of addiction” to treat chronic pain unrelated to cancer. The study said patients in pain would not become addicted to opioids because their pain drowned out the euphoria associated with the drugs.

Within a decade, Portenoy was financed by at least a dozen pharmaceutical companies, most of which produced prescription opioids.

The lawsuit argues that Portenoy’s study – paired with the practice of spending millions of dollars on promotional activities that understated the risks of opioids – not only legitimized but normalized the prescribing of opioids in Dickenson and across the country.

In the case of OxyContin – Purdue’s time-released version of oxycodone – promotional materials given to physicians included this key sentence: “Delayed absorption as provided by OxyContin tablets is believed to reduce the abuse liability of a drug.”

The drug companies’ sales representatives marketed directly to physicians, ensuring that doctors would be advocates for certain drugs, the lawsuit said. As a result, it contended, the pharmaceutical manufacturers were able to insert their products directly into specific markets.

In 2014 alone, the manufacturing defendants named in the Dickenson lawsuit spent more than $168 million on pursuing branded opioid sales contracts with doctors, the lawsuit said.

Twenty-six years after publishing his study justifying the prescription of opioids, Portenoy acknowledged that he erred in understating the risks of addiction associated with such drugs.

“Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did,” Portenoy said in an interview that year with The Wall Street Journal. “We didn’t know then what we know now.”

How pharmacy benefit managers influence drug prices

As explained in the lawsuit, pharmacy benefit managers, or PBMs, are the middleman between the manufacturers and the marketplace; they influence which drugs are used most frequently, set prices for pharmacies and control what drugs are covered by health insurance providers.

PBMs include Caremark, Express Scripts and OptumRX – all named as defendants in the lawsuit. These companies serve as gatekeepers through controlling lists known as “drug formularies” that identify prescription drugs with the greatest overall value.

PBMs and pharmaceutical companies negotiate financial arrangements, including rebates for preferred placement on drug formularies, the lawsuit said. It said manufacturers compete for spots on the list in order to ensure greater utilization of the drugs they make.

Not only do PBMs have the power to make opioids cheaper – they can make less addictive medications harder to acquire, the lawsuit said. For example, it said, United Healthcare places morphine on its lowest-cost coverage tier with no prior permission required; in contrast, Lyrica, a non-opioid drug prescribed for nerve pain, is on the most expensive tier, requiring patients to try other drugs first.

Not just a health crisis but an economic one

The impact of the opioid epidemic in Dickenson County is multifaceted. While the county’s overdose rates are the most conspicuous consequence of the epidemic, the increased flow of opioids into the region has had a ripple effect on the county’s economy, health care system and workforce.

In 2017, the U.S. Centers for Disease Control and Prevention identified Dickenson County as one of eight Virginia counties that are vulnerable to the rapid dissemination of HIV and hepatitis C infections among people who inject drugs.

L. Christopher Plein, a professor of public administration at West Virginia University, said the opioid epidemic is a public health crisis, but it also has far-reaching economic consequences.

“Communities become severely stressed by having to respond and deal with this crisis, and they may lack the resources to provide treatment, engage law enforcement and provide recovery services,” Plein said. “These communities may not be as attractive to outside investors and businesses if they develop a reputation of being tied to the opioid epidemic.”

The lawsuit argues that the opioid epidemic has significantly and negatively impacted nearly every aspect of the county’s $26 million budget and the public services it provides, including health care, emergency medical services, social services, law enforcement and drug prevention, education and treatment.

Dickenson County has had to buy opioid antagonists such as naloxone – medications that can reverse drug overdoses. Moreover, the county has lost tax revenues because of the opioid crisis, the lawsuit said.

For example, the drug epidemic has affected the job market and workforce in Dickenson County. The Virginia Employment Commission reported last week that Dickenson’s unemployment rate in March was 6.6 percent – double the statewide rate. Dickenson had the fifth-highest jobless rate among Virginia’s 133 counties and cities.

Del. Todd Pillion, R-Abingdon, says these consequences can no longer be ignored.

“Dickenson County is on the tipping point of having an unemployable workforce,” Pillion said. “They have difficulty recruiting industry because the only articles in the news are talking about overdoses and opioids.”

Purdue responds: ‘No longer promoting opioids’

In response to the growing number of lawsuits brought against the company, Purdue Pharma announced in February that it would stop marketing opioid drugs to doctors.

“We have restructured and significantly reduced our commercial operation and will no longer be promoting opioids to prescribers,” the company said in a written statement.

Purdue officials said that they cut their sales staff in half in the week following the announcement and that the remaining staff would pivot to focus on other products.

Kevin Sharp, lead counsel for Dickenson County’s lawsuit, called the announcement a step in the right direction. But he said the damage already inflicted demands a more comprehensive response.

“There’s a lot more that has to be done to solve this problem,” Sharp said. “They have to remedy past harm. And the parties are going to have to work together to find out the best way to minimize – and end if possible – the harm that is being caused.”

Purdue Pharma has yet to file a response to the Dickenson County lawsuit but provided the following statement:

“We are deeply troubled by the prescription and illicit opioid abuse crisis, and we are dedicated to being part of the solution. As a company grounded in science, we must balance patient access to FDA-approved medicines with collaborative efforts to solve this public health challenge.

“Although our products account for less than 2% of the total opioid prescriptions, as a company, we’ve distributed the CDC Guideline for Prescribing Opioids for Chronic Pain, developed three of the first four FDA-approved opioid medications with abuse-deterrent properties and partner with law enforcement to ensure access to naloxone.”

Expanding treatment for opioid addiction

In April 2017, the Virginia Department of Medical Assistance Services launched the Addiction Recovery and Treatment Services program to help increase access to treatment for Virginians battling opioid addiction.

The ARTS program was established primarily to help ease the burden on hospital emergency departments in treating patients with opioid-related issues, particularly in rural areas like Dickenson County.

The program expands treatment to Medicaid recipients by combining traditional medicine with counseling and other support systems. It also offers training and financial incentives to providers to encourage participation among outpatient treatment centers, doctors and hospitals.

“Providers are responding to the critical need for addiction treatment,” said Dr. Katherine Neuhausen, chief medical officer for DMAS. “Today, more than 350 new organizations are providing these life-saving services to Virginia Medicaid members. The number of outpatient opioid treatment services has increased from six to 108, including 79 office-based opioid treatment programs combining medication with counseling and other essential supports.”

According to an evaluation by Virginia Commonwealth University’s Department of Health Behavior and Policy, the program has increased the number of Medicaid recipients receiving treatment for opioid addiction by more than 50 percent, and the number of opioid-related emergency hospital visits by Medicaid recipients declined by nearly one third.

(Editor's Note: According to the data compiled as this story was researched, from 2007-2017 there have been 2 opioid-related deaths in the City of Emporia and 3 in Greensville County. During that time frame 3.2% of the total deaths in the City and 2.3% of the total deaths in the County were opioid-related as compared with the 35.5% mortality rate in Dickenson County - in both 2007 and 2011 more than half of the deaths in Dickenson County were opioid-related)

Southwest Virginia Legislator Targets Opioid Crisis

As a health care professional, state Del. Todd Pillion of Abingdon has a special perspective on the opioid epidemic that has ravaged the localities he represents in Virginia’s General Assembly.

Pillion, a pediatric dentist, has successfully sponsored key legislation to address the crisis. He represents the 4th House District, which includes Dickenson County and parts of Wise, Russell and Washington counties.

“Virginia has become a leader in passing not only legislation but regulations through the Board of Medicine and Dentistry,” Pillion said. “There’s no magic bullet – this epidemic isn’t going to go away no matter what we do. But we have seen improvements.”

During this year’s regular legislative session, the General Assembly passed three opioid-related bills introduced by Pillion, a Republican who was elected in 2014. Gov. Ralph Northam has signed the measures into law:

HB 1556 will add the opiate overdose reversal drug naloxone and other Schedule 5 drugs for which a prescription is required to Virginia’s Prescription Monitoring Program. This will allow the Virginia Department of Health to monitor whether prescribers and dispensers are following state regulations and to deter the illegitimate use of prescription drugs. By adding naloxone to the list, officials can track if it is being co-prescribed with opiates in order to prevent fatal overdoses.

HB 1157 will require the Department of Health to develop and implement a plan of action for substance-exposed infants in Virginia. The plan must support a “trauma-informed approach” to identifying and treating substance-exposed infants and their caregivers, explore how to improve screening of substance-using pregnant women, and use multidisciplinary approaches to intervention and service delivery during the prenatal period and following birth.

HB 1173. Under current law, physicians who prescribe opioids are not required to request information from Virginia’s Prescription Monitoring Program as long as the prescription does not exceed 14 days and is treatment for a surgical or invasive procedure. HB 1173 eliminates the exception for prescriptions related to surgical and invasive procedures to bypass the PMP.

Bristol Virginia Public Schools Superintendent: this bill ‘will equip us to better achieve our vision of enabling all students to thrive’

Washington, D.C. – Yesterday, U.S. Senators Tim Kaine (D-VA), Joe Manchin (D-WV), and Shelley Moore Capito (R-WV) introduced the Handle with Care Act to connect children who experience traumatic events, including domestic violence situations, drug raids, overdoses, and more, to school resources that are designed to provide the child with trauma-informed care.

“All too often, traumatic events have a devastating ripple effect across children’s lives. Given the right resources, schools can play a critical support role for kids impacted by trauma and provide them with a safe haven. I’m proud to partner with Senators Manchin and Capito to help ensure students affected by the opioid crisis and other trauma get the resources they need to thrive,” Kaine said.

“Unfortunately, schools are seeing more and more students dealing with trauma outside of the normal school day,” said Dr. Keith Perrigan, Superintendent of Bristol Virginia Public Schools. “Even though we try to keep that in mind in all of our interactions with students, this bill ensures that lines of communication are open between community agencies as we all try to support our most vulnerable students. The Handle with Care Act will equip us to better achieve our vision of enabling all students to thrive, regardless of the obstacles they may face.”

“We are happy to support legislation that makes the Handle with Care initiative a national model for replication. Crittenton Services, Inc., in West Virginia has been a key partner in this initiative and can attest to the difference it makes when schools, law enforcement and their partners work together with a sense of urgency to mitigate the impact of childhood trauma and support healing for children and youth, particularly marginalized girls and young women, across this country,” said Jeannette Pai-Espinosa, President of the National Crittenton Foundation.

The Handle with Care Act of 2018 is important legislation that will boost coordination between law enforcement and school-level personnel to better support students affected by trauma-related events. We must do all we can to ensure these students receive timely interventions to mitigate the impact of trauma so they can focus on learning,” said Dr. L. Earl Franks, Executive Director of the National Association of Elementary School Principals.

“Nothing offends a principal more than the loss of human potential. Yet every, day, principals see that potential robbed from their students by an opioid epidemic that devastates their schools and their families. With every student who suffers the trauma of opioid abuse, we lose a bit more of our future. I applaud Senators Manchin, Kaine, and Capito for casting a spotlight on this public health crisis and, more important, for championing legislation to battle it,” said Joann Bartoletti, Executive Director of the National Association of Secondary School Principals.

The Handle with Care program, which originated in West Virginia, is as simple as law enforcement sending a “Handle with Care” alert to the child’s school. While the school does not receive any information other than the child’s name and the alert, it enables the school to exercise the trauma-informed training provided in coordination with the Handle with Care program. The goal of the program is to promote safe schools, and communities, while ensuring that every child is able to thrive in school even when they face trauma at home.

The Handle with Care Act would authorize $10 million in federal funding to establish 5-year demonstration grants for states to address the impact of substance use related and other trauma on children and youth in public schools by strengthening or building Handle with Care programs. These programs would:

Develop and share evidence-based or evidence-informed training for trauma informed care and provide that training in schools connected to the program.

Connect students who experience trauma at home to those resources in schools via the “Handle with Care” alert from law enforcement.

Require programs to report on the success of the Handle with Care programs in improving student outcomes.

RICHMOND -- An average of 19 people a week overdosed on opioids in Richmond last year, and government agencies and other entities have responded to the crisis in a variety of ways, from dispensing overdose reversal drugs to arresting addicts.

Academic and law-enforcement experts discussed the problem and possible solutions Tuesday in a panel discussion titled "The Opioid Epidemic: Impact on Communities" at Virginia Commonwealth University.

“It is our problem, and it is our responsibility,” said Kate Howell, an assistant professor at VCU’s L. Douglas Wilder School of Government and Public Affairs.

“Addiction is not new,” Howell said. “What is new is the drugs are more powerful and affordable than they were in the past and easier to get.”

Amy Cook, also an assistant professor in the Wilder School, said there are three approaches to combating the epidemic:

Expansion of community-based services

Recovery housing

Needle exchange programs

In 2017, the Virginia General Assembly legalized needle exchange services -- but no program has been implemented in the commonwealth.

Cook said needle exchanges recognize the multidimensional factors needed to treat addiction. However, she said, there is not a “one size fits all” approach.

“Were looking at a variety of treatment approaches -- community-based, sociological issues, biological issues,” Cook said. “The key part is, you have to be able to address it all and monitor it all -- and when it’s not monitored, that’s where we drop the ball.”

Chesterfield County Sheriff Karl Leonard said he uses an “arrest them all” strategy when it comes to preventing overdoses.

“There is no other program for them to get the help they need,” Leonard said. “At least arresting and bringing them in, they’re alive.”

Leonard said he doesn’t want to arrest addicts, but said the resources they need aren’t accessible in most communities. Through the “arrest them all” strategy, Leonard allows addicts to get off the street and sober.

“In 37 years, I never saw any drug as harmful, as plentiful, as cheap as heroin,” he said. “As a state, we’re failing."

The leading causes of unnatural death in Virginia from 2007 to 2013 were motor vehicle collisions, gun-related deaths and fatal drug overdoses. In 2013, fatal drug overdoses became the leading cause, according to the Virginia Department of Health.

First responders who work with the Richmond Ambulance Authority have seen a spike in the number of opioid overdose patients in recent years. They estimate using about 1,000 doses of the overdose revival drug Naloxone to save people’s lives last year.

The opioid crisis has affected people not only in cities but also in suburban and rural areas, especially in Appalachia. That has made the problem hard to ignore.

“It wasn’t a crisis until it hit a group of communities we can’t ignore,” Howell said. ”Once it hit our suburban communities, they called it a problem. It sets up this dichotomy where we expect a certain kind of people. Now it’s different; we say, ‘Oh no, we have to do something.’”

The Emporia Police Department has changed several of its telephone numbers. Please use the numbers below to replace any numbers you are currently using. Even though some older numbers may still be working now, they will eventually be removed.

911 Communications Center Non-Emergency number:

434-634-7320

Emporia Police Administrative Offices:

434-634-2121

As always, please use 911 for all emergency calls.

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